This exploratory R21 proposal addresses a significant clinical problem of public health interest: Medication safety for residents in rural Assisted Living (AL) settings. Adverse drug events (ADEs) affect both quality of life and health care costs. AL residents are at risk for ADEs by virtue of their advanced age, frailty, and the prevalence of high-risk medications. In AL, the benefits of resident freedom and lighter regulatory structure are balanced by the risk for deleterious outcomes for vulnerable residents. These issues are magnified in rural communities, where elders have a greater prevalence of chronic illness and rural services (primary care, long term care, and pharmacy) are more limited. Medication assistance is a common service in AL, either self-administered by residents or provided by unlicensed assistive personnel (UAP), with limited professional involvement, reducing the potential for identification of ADEs. Indeed, medication management is one of the top three quality issues in AL. Research on medication safety in rural AL is in its earliest stages, with no data on the incidence of ADEs or on how facilities promote and monitor medication safety. While training for UAP is often recommended, specific content has not been identified. The long term goal of this research program is to improve quality of medication service, reduce inappropriate medication use in AL, and improve function and quality of life by developing and testing an intervention to improve medication safety in AL. The objective of this R21 application is to specify the content for the proposed intervention and to conduct feasibility testing of measures related to medication safety to facilitate process (i.e., skill) and outcome (i.e., errors/ADE) evaluation for the subsequent intervention study. The specific aims are: 1) To identify communication structures and processes in AL that potentially promote or impede medication safety and 2) To evaluate the feasibility of process and outcome measures related to medication safety. Data will be collected from 8 rural AL settings in Oregon and Washington, over a 6-month period. Methods will include focused interviews, observations, and record review. These aims are innovative in both content and method. The results of this study will provide valuable pilot data for the development and testing of nursing interventions to improve quality of care in AL.